1. PFF Teal = 0+160+175 MAIN COLORS PFF Green = 120+162+47 Light Green = 193+216+47 Red = 242+102+73 HIGHLIGHT COLORS Light Grey = 220+220+210 Dark Grey = 100+98+76 Black = 0+0+0 PATIENT AND CAREGIVER PULMONARY REHABILITATION WORKSHOP ANNE HOLLAND, PT, PhD CHRIS D. SCHUMANN, MS, CES, RCEP TAKING CARE OF YOURSELF: SHARED HEALTHCARE DECISION-MAKING NOVEMBER 13, 2015

2. PFF Teal = 0+160+175 MAIN COLORS PFF Green = 120+162+47 Light Green = 193+216+47 Red = 242+102+73 HIGHLIGHT COLORS Light Grey = 220+220+210 Dark Grey = 100+98+76 Black = 0+0+0 PULMONARY REHABILITATION “Is a comprehensive intervention based on a thorough patient assessment followed by patient tailored therapies that include, but are not limited to, exercise training, education, and behavior change, designed to improve the physical and psychological condition of people with chronic respiratory disease and to promote the long- term adherence to health-enhancing behaviors.” American Thoracic Society/ European Respiratory Society

3. PFF Teal = 0+160+175 MAIN COLORS PFF Green = 120+162+47 Light Green = 193+216+47 Red = 242+102+73 HIGHLIGHT COLORS Light Grey = 220+220+210 Dark Grey = 100+98+76 Black = 0+0+0 PULMONARY REHABILITATION Each program varies, but here are some common features:  Outpatient settings  Lasts 6 to 12 weeks  Attend 2-3 times/week  Includes exercise on a stationary bike, treadmill, arm cycle and light weights You need a referral from your physician to start a pulmonary rehab program 3

4. PFF Teal = 0+160+175 MAIN COLORS PFF Green = 120+162+47 Light Green = 193+216+47 Red = 242+102+73 HIGHLIGHT COLORS Light Grey = 220+220+210 Dark Grey = 100+98+76 Black = 0+0+0 PULMONARY REHABILITATION TEAM Interdisciplinary Team: – Core staff Medical Director Program Manager Registered Nurse Respiratory Therapist Exercise Physiologist Clerical (Admissions) – Resource professionals Dietitian Diabetes Educator Nurse Practitioner Pulmonary Fellows Mental Health Specialist (Clinical Psychologist) Pharmacist Social Worker Volunteers

5. PFF Teal = 0+160+175 MAIN COLORS PFF Green = 120+162+47 Light Green = 193+216+47 Red = 242+102+73 HIGHLIGHT COLORS Light Grey = 220+220+210 Dark Grey = 100+98+76 Black = 0+0+0 PULMONARY REHABILITATION SERVICES ARE DESIGNED FOR THOSE WHO EXPERIENCE LUNG PROBLEMS SUCH AS: COPD – Bronchitis – Asthma – Bronchiectasis – Cystic Fibrosis Interstitial Lung Disease Pulmonary Fibrosis Pulmonary Hypertension Pre and post lung transplantation

6. PFF Teal = 0+160+175 MAIN COLORS PFF Green = 120+162+47 Light Green = 193+216+47 Red = 242+102+73 HIGHLIGHT COLORS Light Grey = 220+220+210 Dark Grey = 100+98+76 Black = 0+0+0 PULMONARY REHABILITATION HELPS PARTICIPANTS: Experience less difficulty with breathing Increase muscle strength and endurance Improve your ability to cope with daily activities Understand how to use medications and oxygen appropriately Improve your quality of life Reduce hospitalizations AACVPR.ORG

7. PFF Teal = 0+160+175 MAIN COLORS PFF Green = 120+162+47 Light Green = 193+216+47 Red = 242+102+73 HIGHLIGHT COLORS Light Grey = 220+220+210 Dark Grey = 100+98+76 Black = 0+0+0 PULMONARY REHABILITATION PROGRAMS INCLUDE: Monitored and supervised exercises Education about your pulmonary condition, control of symptoms, medications, and oxygen Assistance with smoking cessation Stress reduction and/or management techniques sessions Nutritional counseling/classes

8. PFF Teal = 0+160+175 MAIN COLORS PFF Green = 120+162+47 Light Green = 193+216+47 Red = 242+102+73 HIGHLIGHT COLORS Light Grey = 220+220+210 Dark Grey = 100+98+76 Black = 0+0+0 SERVICES PROVIDED IN PULMONARY REHABILITATION Exercise assessment Assessment of O2 requirements Exercise training Education topics related to disease management Nutrition evaluation and counseling

9. PFF Teal = 0+160+175 MAIN COLORS PFF Green = 120+162+47 Light Green = 193+216+47 Red = 242+102+73 HIGHLIGHT COLORS Light Grey = 220+220+210 Dark Grey = 100+98+76 Black = 0+0+0 Pulmonary Rehabilitation Assessment ©2015 Pulmonary Fibrosis Foundation. All rights reserved.9

10. PFF Teal = 0+160+175 MAIN COLORS PFF Green = 120+162+47 Light Green = 193+216+47 Red = 242+102+73 HIGHLIGHT COLORS Light Grey = 220+220+210 Dark Grey = 100+98+76 Black = 0+0+0 PULMONARY REHABILITATION Medical history review – PFT, CXR, Clinic visit, etc. Medications Oxygen – O2 flowrate at rest and with activity Resting vitals – O2 saturation, HR, BP, baseline shortness of breath rating, ECG if necessary Baseline questionnaire – Health-related quality of life, Psychosocial, Mood, Diet, etc.

11. PFF Teal = 0+160+175 MAIN COLORS PFF Green = 120+162+47 Light Green = 193+216+47 Red = 242+102+73 HIGHLIGHT COLORS Light Grey = 220+220+210 Dark Grey = 100+98+76 Black = 0+0+0 EXERCISE ASSESSMENT Essential to allow an individualized exercise prescription Often includes a 6-minute walk test Sometimes a cycle exercise test Gives lots of useful information: – How much exercise you can do – Heart rate responses to exercise – Oxygen desaturation during exercise – Symptoms – often breathlessness, but often leg fatigue too – Limitations to exercise – eg lower limb arthritis

12. PFF Teal = 0+160+175 MAIN COLORS PFF Green = 120+162+47 Light Green = 193+216+47 Red = 242+102+73 HIGHLIGHT COLORS Light Grey = 220+220+210 Dark Grey = 100+98+76 Black = 0+0+0 ASSESSING OXYGEN NEEDS At Rest – Oxygen need may not be needed in early stages of disease. Supply meets demand With Exercise – Desaturation is the hallmark feature of PF Hypoxemia results in: – Increase in pulmonary vascular resistance (VR) – Increased myocardial work – Decreased oxygen delivery to muscles » Symptoms, muscle fiber/cellular changes – The increased VR can increase pulmonary artery pressure Your PR team will assess your current oxygen needs both at rest and during exercise

13. PFF Teal = 0+160+175 MAIN COLORS PFF Green = 120+162+47 Light Green = 193+216+47 Red = 242+102+73 HIGHLIGHT COLORS Light Grey = 220+220+210 Dark Grey = 100+98+76 Black = 0+0+0 Exercise Prescription for Pulmonary Patients ©2015 Pulmonary Fibrosis Foundation. All rights reserved.13

14. PFF Teal = 0+160+175 MAIN COLORS PFF Green = 120+162+47 Light Green = 193+216+47 Red = 242+102+73 HIGHLIGHT COLORS Light Grey = 220+220+210 Dark Grey = 100+98+76 Black = 0+0+0 EXERCISE TRAINING IN PULMONARY REHABILITATION Tailored to your needs General goals of exercise: – Increase strength and endurance – Increase functional capacity – Improve quality of life – Reduce symptoms Likely that with expert exercise prescription and supervision, you can do more than you expect Goal: 30 mins of endurance exercise (we work up to it!)

15. PFF Teal = 0+160+175 MAIN COLORS PFF Green = 120+162+47 Light Green = 193+216+47 Red = 242+102+73 HIGHLIGHT COLORS Light Grey = 220+220+210 Dark Grey = 100+98+76 Black = 0+0+0 EXERCISE TRAINING Maintain adequate oxygen saturation during exercise, >88%. – Understand O2 flowrate requirements with various levels of exercise intensity – Understand the portable oxygen system better (demand vs. continuous) – Understand how pacing and breathing techniques might help ATS/ERS, AJRCCM 10/2013

16. PFF Teal = 0+160+175 MAIN COLORS PFF Green = 120+162+47 Light Green = 193+216+47 Red = 242+102+73 HIGHLIGHT COLORS Light Grey = 220+220+210 Dark Grey = 100+98+76 Black = 0+0+0 HOW MUCH EXERCISE? FITT Principle – Frequency, Intensity, Time, Type – Endurance training Frequency – 3-5 days per week Intensity – >60% of maximal work rate (moderate) Time – 20 to 60 minutes Type – walking, treadmill, stationary cycle, etc. ATS/ERS, AJRCCM 10/2013

17. PFF Teal = 0+160+175 MAIN COLORS PFF Green = 120+162+47 Light Green = 193+216+47 Red = 242+102+73 HIGHLIGHT COLORS Light Grey = 220+220+210 Dark Grey = 100+98+76 Black = 0+0+0 HOW MUCH EXERCISE? FITT – Frequency, Intensity, Time, Type – Strength training Frequency – 2-3 days per week Intensity – 60-70% of one repetition max 8-12 repetitions 1-3 sets Time – 20-30 minutes Type – 8-10 exercises (Upper and lower body) ©2015 Pulmonary Fibrosis Foundation. All rights reserved.17

18. PFF Teal = 0+160+175 MAIN COLORS PFF Green = 120+162+47 Light Green = 193+216+47 Red = 242+102+73 HIGHLIGHT COLORS Light Grey = 220+220+210 Dark Grey = 100+98+76 Black = 0+0+0 HOW MUCH EXERCISE? Flexibility Training – 2-3 days per week – Perform upper and lower body flexibility exercises Major muscle groups Focus placed on good posture and proper breathing techniques – NOT a substitute for endurance and strength training – (if you have to pick one type of exercise, don’t pick this one) ©2015 Pulmonary Fibrosis Foundation. All rights reserved.18

19. PFF Teal = 0+160+175 MAIN COLORS PFF Green = 120+162+47 Light Green = 193+216+47 Red = 242+102+73 HIGHLIGHT COLORS Light Grey = 220+220+210 Dark Grey = 100+98+76 Black = 0+0+0 Non-exercise components of Pulmonary Rehabilitation ©2015 Pulmonary Fibrosis Foundation. All rights reserved.19

20. PFF Teal = 0+160+175 MAIN COLORS PFF Green = 120+162+47 Light Green = 193+216+47 Red = 242+102+73 HIGHLIGHT COLORS Light Grey = 220+220+210 Dark Grey = 100+98+76 Black = 0+0+0 NON-EXERCISE COMPONENTS Often find yourself in an education group with people who have other lung diseases Some education and management topics are common across disease groups: – how the lungs work, establishing a home exercise program, healthy eating, using oxygen etc Some are different – treatments and their side effects, participating in clinical trials, managing cough Your team will tailor your program to your needs

21. PFF Teal = 0+160+175 MAIN COLORS PFF Green = 120+162+47 Light Green = 193+216+47 Red = 242+102+73 HIGHLIGHT COLORS Light Grey = 220+220+210 Dark Grey = 100+98+76 Black = 0+0+0 NON-EXERCISE COMPONENTS Pulmonary rehabilitation is a great opportunity to maximize your health across a range of important areas A range of health care professionals often available to help you to do this: – Nurse – Nutritionist – Diabetes Educator – Pharmacist – Social Worker

22. PFF Teal = 0+160+175 MAIN COLORS PFF Green = 120+162+47 Light Green = 193+216+47 Red = 242+102+73 HIGHLIGHT COLORS Light Grey = 220+220+210 Dark Grey = 100+98+76 Black = 0+0+0 Is there scientific evidence to support pulmonary rehabilitation in PF? ©2015 Pulmonary Fibrosis Foundation. All rights reserved.22

23. PFF Teal = 0+160+175 MAIN COLORS PFF Green = 120+162+47 Light Green = 193+216+47 Red = 242+102+73 HIGHLIGHT COLORS Light Grey = 220+220+210 Dark Grey = 100+98+76 Black = 0+0+0 SCIENTIFIC EVIDENCE TO SUPPORT PR IN PF? Effects are big enough for most people to notice Significant gains in exercise capacity, symptoms and quality of life Dowman et al Cochrane 2014 Better with PR

24. PFF Teal = 0+160+175 MAIN COLORS PFF Green = 120+162+47 Light Green = 193+216+47 Red = 242+102+73 HIGHLIGHT COLORS Light Grey = 220+220+210 Dark Grey = 100+98+76 Black = 0+0+0 SCIENTIFIC EVIDENCE FOR PR Studies have demonstrated improvements in exercise capacity, symptoms and health-related quality of life in patients with PF following PR Longer term benefits less clear 24

25. PFF Teal = 0+160+175 MAIN COLORS PFF Green = 120+162+47 Light Green = 193+216+47 Red = 242+102+73 HIGHLIGHT COLORS Light Grey = 220+220+210 Dark Grey = 100+98+76 Black = 0+0+0 Maintaining the benefits of pulmonary rehabilitation ©2015 Pulmonary Fibrosis Foundation. All rights reserved.25

26. PFF Teal = 0+160+175 MAIN COLORS PFF Green = 120+162+47 Light Green = 193+216+47 Red = 242+102+73 HIGHLIGHT COLORS Light Grey = 220+220+210 Dark Grey = 100+98+76 Black = 0+0+0 MAINTAINING THE BENEFITS OF PR: THE BIGGEST CHALLENGE Holland et al Thorax 2008

27. PFF Teal = 0+160+175 MAIN COLORS PFF Green = 120+162+47 Light Green = 193+216+47 Red = 242+102+73 HIGHLIGHT COLORS Light Grey = 220+220+210 Dark Grey = 100+98+76 Black = 0+0+0 MAINTAINING THE BENEFITS OF PR: THE BIGGEST CHALLENGE Holland et al Thorax 2008 Developing a home exercise program is critical Work out what type of exercise you like (or don’t dislike!) Test out your home program whist you are in the supervised rehab program, so that there is someone who can help you troubleshoot

28. PFF Teal = 0+160+175 MAIN COLORS PFF Green = 120+162+47 Light Green = 193+216+47 Red = 242+102+73 HIGHLIGHT COLORS Light Grey = 220+220+210 Dark Grey = 100+98+76 Black = 0+0+0 Coverage of PR ©2015 Pulmonary Fibrosis Foundation. All rights reserved.28

29. PFF Teal = 0+160+175 MAIN COLORS PFF Green = 120+162+47 Light Green = 193+216+47 Red = 242+102+73 HIGHLIGHT COLORS Light Grey = 220+220+210 Dark Grey = 100+98+76 Black = 0+0+0 PRIMARY INSURANCE COVERAGE AND COPAYS Coverage is typical, but not guaranteed. Coverage will depend on your specific plan and diagnosis. Medicare - 80% coverage Secondary Insurance – 20% Traditional primary insurance - 80% coverage CMS G0237Therapeutic procd. strg. endur.Q17733$93.27$18.66 G0238Oth. resp. proc., indiv.Q15733$56.70$11.34 G0239Oth. resp. proc., group.Q15732$31.03$6.21 CY 2016 Proposed Payment Rates HCPCS CodeServiceStatus Indicator APCPayment RateCo-Payment

30. PFF Teal = 0+160+175 MAIN COLORS PFF Green = 120+162+47 Light Green = 193+216+47 Red = 242+102+73 HIGHLIGHT COLORS Light Grey = 220+220+210 Dark Grey = 100+98+76 Black = 0+0+0 Questions?

31. PFF Teal = 0+160+175 MAIN COLORS PFF Green = 120+162+47 Light Green = 193+216+47 Red = 242+102+73 HIGHLIGHT COLORS Light Grey = 220+220+210 Dark Grey = 100+98+76 Black = 0+0+0 Thank you.